City of St. Louis Jail Diversion Project Final Evaluation Report

Transcription

1 City of St. Louis Jail Diversion Project Final Evaluation Report Prepared for the The City of St. Louis Department of Human Services by Michael M. Orihuela MSW L. Anthony Loman, Ph.D. Institute of Applied Research St. Louis, Missouri June 2010

2 Copyright 2010 by the Institute of Applied Research 103 W Lockwood, Suite 200 St. Louis, Missouri (314) iar@iarstl.org website: This document may be copied and transmitted freely. No deletions, additions or alterations of content are permitted without the express, written consent of the Institute of Applied Research. ii

3 Table of Contents Section page Key Highlights... iv 1. Introduction Selected Findings of Early Project Reports Study Design and Data Collection The Evaluation Sample Characteristics of the Jail Diversion Participants Criminal History and Screening Treatment Services Outcomes: Feedback from Consumers Conclusions and Recommendations References Appendix A: Participating Agencies Appendix B: Data Sources Appendix C: Consumer Feedback Appendix D: Summary of Consumer luncheon Meetings iii

4 Key Highlights The St. Louis City Jail Diversion Project was developed through a collaborative planning process among criminal justice and community treatment agencies. Through the project, individuals with mental health problems were diverted from the criminal justice system into mental health treatment services. The project was funded through a Federal Substance Abuse and Mental Health Services Administration (SAMHSA) grant from May 2006 to April Community Alternatives and BJC Behavioral Health, St. Louis City behavioral healthcare providers, provided integrated treatment services combined with best practice approaches for clients involved in the criminal justice system. The Center for Trauma Recovery of the University of Missouri St. Louis provided trauma therapy. Program participants were enrolled in services and asked to participate voluntarily in a longitudinal evaluation of services. The evaluation operated from August 2007 through April Key highlights of the evaluation report include the following: Screenings were conducted for 477 individuals. Of these, 167 were screened in and diverted from jail to community mental health treatment. Among those screened out were 129 that met initial screening criteria but for various reasons did not complete the planning process for presentation to the courts; 89 that did not meet legal criteria; and 92 that either did not meet psychiatric criteria, were referred elsewhere, or were released from custody. The majority (57 percent) of clients in jail diversion programs had severe and persistent mental illness. A large majority (78 percent) of participants were also identified as having alcohol or drug abuse issues at the time of enrollment. Of those successfully diverted, 69 percent completed a minimum of 24 weeks of supervision and community-based outpatient treatment services which utilized evidence-based integrated treatment services. Overall improvement was observed among participants on measures of mental health symptoms (frequency and severity) and daily functioning outcomes at six months and twelve months after entering the program. Substance use, as reported by participants, declined from 43 percent at baseline to seven percent at six months and 10 percent at twelve months, including similar patterns of improved outcomes for those reporting any alcohol use and alcohol use to intoxication. Based on initial measures of posttraumatic stress disorder (PTSD), 60 percent of participants were determined to have probable PTSD at the time of enrollment. A minority (13 percent) received treatment specifically directed at trauma recovery, yet a reduction in PTSD symptoms was observed among the entire population from 60 percent at entry to 39 percent at six months and 28 percent after one year. iv

5 Clients in jail diversion program moved to more independent and desirable living situations. Among those interviewed at six months, stable housing had increased from 27 percent to 40 percent, while homelessness had decreased from 24 percent to 3 percent. Diversion program participants who successfully completed the jail diversion program were significantly less likely to return to the criminal justice system during the 12 months following diversion. In addition, program graduates had better outcomes in other areas including stable housing, enrollment in school and engagement in mental health treatment. v

6 1. Introduction This is the final report on the St. Louis Jail Diversion Project (SLJDP). The SLJDP is a program for arrested and locally incarcerated mentally ill individuals in St. Louis City to divert them from jail or prison to mental health, substance abuse and support services. This report describes findings in three general areas: characteristic of participants, treatment services, and outcome measures. In addition, select findings of earlier evaluation reports are summarized. The SLJDP is a project of the City of St. Louis and is administered by the City Department of Human Services. From 2006 through April 2010 the SLJDP was funded through a Federal Substance Abuse and Mental Health Services Administration (SAMHSA) grant. The SAMHSA grant provided for a one-year planning period from May 2006 through April 2007, during which agency representatives (listed in Appendix A) met and worked together to design the program. This was to be followed by a two-year service program. After some delays, the first clients were accepted during August The program operated under the original grant through April At that time, the city was granted a one-year no-cost extension of the SAMHSA grant to continue serving clients through April As, noted below, the jail diversion program is now continuing under local funding. The SLJDP is a consortium of criminal justice agencies and community treatment and service programs. The organizations and agencies are listed in Appendix A of this report. The project has as its primary goal diversion of individuals with mental health problems to needed therapeutic and social services rather than to jail or the prison system. Individuals entering the project must be 18 year old or older with a mental illness. The diagnostic focus described in the original SLJDP strategic plan was on individuals with Axis I disorders including psychotic, debilitating mood or severe anxiety disorders. Concerning the latter, there was to be a special emphasis on posttraumatic stress disorder (PTSD). Because nationally 70 percent or more of mentally ill defendants also have co-occurring substance abuse disorders, it was expected that the majority of individuals entering the SLJDP would have a substance abuse disorder. Based on a needs assessment completed during the planning period, it was also assumed that most participants would be indigent and some would be homeless. Participation in the SLJDP was and continues to be voluntary. Jail diversion participation is limited to individuals charged with nonviolent violations of St. Louis City ordinances, nonviolent Missouri State misdemeanors or nonviolent federal felony offenses. City defendants enter through the St. Louis City Municipal Court while state defendants are received through the Division 26 Misdemeanors/Traffic of the 22 nd Judicial Circuit Court. Potential participants from these two sources have been recently arrested and are awaiting arraignment. Federal defendants are received from the United States Pre-Trial Services Office as well as the U.S. Probation Office, Eastern District of Missouri. Individuals considered for participation from this source were previously diverted by the U.S. Attorney and are already participating in the Pre-Trial Services Program. Treatment services are available through Community Alternatives Inc., Barnes-Jewish-Christian (BJC) Hospital Behavioral Health Services and the Center of Trauma Recovery of University of Missouri-St. Louis. The Institute of Applied Research (IAR) was associated with the SLJDP from the time of the initial grant and 1

7 through the planning period. IAR participated in planning and conducted an initial needs assessment. After the planning period, IAR served as the project evaluator. Goals of the Project The goals of the project were defined under the original SAMHSA grant proposal. These included the following: 1. Divert people with mental illness. 2. Provide Evidence-based Practice. 3. Reduce recidivism to the criminal justice system via new arrests, court appearances and incarceration. 4. Improve mental health and substance abuse outcomes of participants. 5. Improve participant s social service outcomes (housing, employment). 6. Develop a better coordinated, a more highly responsive and a more effective system of care for people with mental illness who are involved in criminal justice system. These goals are considered in detail in the following sections. Project Sustainability A requisite of the SAMHSA award was the responsibility of each grantee to secure funding to sustain the project at the end of the grant period. In May 2010, the St. Louis Jail Diversion Project secured a three year grant form the St. Louis Mental Health Board to provide outreach community based treatment, medication, support services, case management and trauma recovery treatment for the period of July 2010 through June Findings of Earlier Project Reports In this section, select findings of the initial needs assessment and the first process evaluation report are considered. They are presented first to inform the reader about available information and opinions of experts concerning the need for jail diversion and the needs of potential SLJDP clients. Secondly, the early process study findings highlight some of the initial problems encountered in initiating a project that involved coordination of several diverse agencies. This information may also be useful to individuals interested in establishing jail diversion programs in other jurisdictions. 2

8 Select Findings of the St. Louis Jail Diversion Project Needs Assessment The first year of the SLJDP was devoted to planning and coordination. To assist in the planning process, IAR conducted a needs assessment and completed a formal report in June Information on the number of St. Louis City offenders and their characteristics was obtained from the St. Louis City Justice Center (city jail and workhouse) and the U.S Pretrial Diversion Office. In addition, a key informant survey was conducted of individuals knowledgeable about the criminal justice system, mental health/substance treatment system, or both. Criminal charges and demographic characteristics. The populations of the two potential sources of SLJDP clients (Justice Center and Federal Pretrial) were quite different. 1 Because SLJDP planners sought to limit the project to various non-violent offenses, only misdemeanors and city ordinance violations were examined for arrested individuals at the Justice Center. The most common charges in these categories were traffic- and vehicle-related, courtrelated (such as failure to appear) and public-behavior offenses. The latter included street demonstrations, peace disturbances, trespassing, public drinking, urinating in public and other similar charges. Slightly more than a quarter (26 percent) of charges included petty larceny and misdemeanor theft, such as possession of stolen property and shoplifting; third degree assault; resisting arrest and domestic assault; and alcohol- and drug-related charges. The most frequent categories of (non-violent felony) charges for U.S. Pretrial Services offenders were fraud, followed by financially-related or theft charges, such as counterfeiting, embezzlement, forgery, mail theft/fraud, and larceny. Small minorities of offenders were charged with drug offenses, federal statute violations and other charges. All charges of offenders in the Federal pretrial program were non-violent. The average offender in the St. Louis City system was male (82 percent), 20 to 40 years old (79 percent) and African American (83 percent). Federal Pretrial offenders were more likely to be female (56 percent) and Caucasian (57 percent). National studies have shown mental illness to be highest among the middle-aged jail and prison populations (Ditton, 1999). Daily population and mental illness. Based on past statistics, the average daily population (per month) in the City system was expected to range from 1,450 to 1,670 individuals. Daily population figures were not available for U.S. Pretrial but a recent count of offenders under active supervision at the time of the needs assessment was 144. The latest information at the Justice Center indicated about 600 encounters per month for mental health reasons. Because some individual were encountered two or more times per month, the actual number of jail inmates with these conditions was lower, possibly 300 or fewer. Other statistics indicated that 20 to 40 individuals were assigned to close observation and 12 to 40 were assigned to suicide watch each month. The medical unit director felt that the majority of offenders seen for mental illness were charged with felonies. However, national statistics 1 The St. Louis City Justice Center includes the city jail and city workhouse (Median Security Institution for prisoners convicted of misdemeanor crimes). Arrestees include individuals entering the court system of the City and the State of Missouri. 3

9 indicate that a large proportion of individuals who enter the justice system with mental illness (and substance abuse disorders) are charged with misdemeanor crimes (Ditton, 1999). U.S. Pretrial offenders with reported mental health problems constituted about seven percent of the active population. Data available for this population showed that the large majority reported drug or alcohol abuse problems at the start of supervision. No comparable drug and alcohol data for the City population were available. However, based on national statistics, it was assumed that most of jailed individuals with serious mental illness would have co-occurring substance abuse disorders (Bureau of Justice Statistics, 2006). Furthermore, studies show that about half of mentally ill individuals that return to the justice system within one year do so because co-occurring disorder treatment was not pursued (Solomon, 1994). There were 17 respondents to the key informant survey. Key informants indicated that (among St. Louis City arrestees) various kinds of public behavior crimes would be commonly encountered and were the most suitable offenses to be targeted by the SLJDP. These included trespassing, disorderly conduct, loitering/vagrancy, public intoxication, aggressive begging/panhandling, street demonstration, indecent exposure, urinating in public, and the like. The kinds of charges seen among Federal Pretrial offenders (mail fraud, forgery, embezzlement) were generally rated lower by key informants, although national statistics indicate that such offenses are also represented among mentally ill jail population inmates (Ditton, 1999). Several respondents implied or stated explicitly that type of offense should not be taken as an index of suitability or unsuitability for diversion. Rather the circumstances of the charge should be considered. Key informants indicated that criminal records should be assessed with an eye to the circumstances and level of risk associated with past offenses, and whether the offenses were related to the individual s mental illness or drug/alcohol dependence. History of violent offenses, sexual offenses and escape charges were mentioned as reasons for exclusion from the program. Respondents rated female offenders and developmentally disabled offenders as more suitable for jail diversion. Offenders in the 22 to 30 year age range were given priority over offenders 21 years and younger. Respondents also indicated that along with veterans, homeless persons and individuals not in treatment at the time of the offense should be targeted. Among the needs of St. Louis City offenders who are mentally ill, respondents most frequently cited: Unemployment, underemployment and homelessness. Federal pretrial offenders were regarded as slightly better off in these areas. All respondents felt that a majority or more of City offenders were in poverty. Again, the expectation for Federal pretrial offenders was more mixed although most respondents believed that the majority were poor. Lack of access to substance abuse treatment and lack of access to psychiatric medications were seen as roughly equivalent between the two groups. Lack of health care was seen as about the same between the two groups but the absence of mental health treatment and Medicaid were regarded as more acute among the Federal offenders. Poor psychological functioning was considered high in both, although multiple psychological disorders were expected more often among the city and state offenders. Social isolation as indicated by the lack of family support was expected to be high in both groups of offenders. Respondents also spontaneously reported lack of education or skill training, lack of transportation and the absence of housing support. 4

10 Services Needed. Key informants ranked services needed in various ways but reported the following most frequently among the top three: o Medication monitoring and medication to control symptoms o Psychiatric evaluation o Supported Living and transitional living services o Service coordination and referral o Assertive community treatment o Employment services o Housing access o Outpatient and inpatient alcohol and drug treatment o Individual counseling/therapy Barriers to Jail Diversion. The most frequently mentioned barrier concerned how the parts of the system would work together, including problems in communication and coordination between the judicial system and community providers of treatment. A structure of regular and daily communication between all components of the diversion program was regarded as necessary. Some also cited lack of coordination within the judicial system and fragmentation of services within the community service system. Various specific barriers and needs were also mentioned: 1) housing shortages, 2) problems accessing employment services, 3) lack of employment opportunities, 4) insufficient community-based mental health services, 5) lack of transportation to services, 6) problems accessing public education, and 7) low community support, both business and religious There was agreement that trained screeners and case managers in both the criminal justice system and in treatment services would be needed. Some thought that various specialists would be useful, in such areas as housing, job placement and legal services. The expected profiles for substance abuse also differed between the two groups. City/state offenders were expected to be mostly crack/cocaine and alcohol abusers with only a minority expecting heroin or methamphetamines abuse. The two latter categories were expected more frequently on the U.S. Pretrial side. Expectations of marijuana use were roughly equivalent. 5

11 These findings from the needs assessment survey were used by SLJDP planners as they designed the structure and procedures that were to be implemented during the 2007 to 2010 project period. Select Findings of the First SLJDP Process Evaluation Reports Clients were accepted into the St. Louis Jail Diversion Project during the final five months of the In early 2008 evaluators reported findings of the first process evaluation of the project. The evaluation pointed to several areas of concern that are summarized in this section. The problems were addressed by SLJDP staff and largely resolved in the months following the process evaluation report. They and the solutions are presented here because they represent common problems experienced in initiating new programs that might be avoided by incorporating the solutions into initial structure and procedures. Inappropriate Referrals from the City and State Courts. Most early referrals were state and local arrestees (78 percent) who had been assessed by St. Louis City Justice Center (SLCJC) health professionals and judged likely to suffer mental health problems. A major problem with this process was that early in the program referring agencies were largely unfamiliar with program criteria and a number of inappropriate referrals were submitted for screening. For example, 56.7 percent of non-eligible referrals were screened out because legal criteria barred their participation in the program. Some were charged with state or local felonies. Others were multiple offenders with outstanding arrest warrants in surrounding jurisdictions. In the latter cases, individuals may well have been appropriate on the basis of mental health criteria for entry into the program but enrolling individuals with outstanding warrants in other jurisdictions would have been problematic unless consent from courts in other jurisdictions was obtained prior to enrollment. Other reasons for bad referrals included individuals that were already receiving services, were not interested in the program, or who had a violent history. During this early period, some of the probation officers responsible for screening had not been trained to look up criminal records of individuals referred. This resulted in delays in obtaining information on the legal standing of referrals and ultimately delaying a key stage of eligibility. Solution. The key probation officer responsible for screening was trained to conduct criminal record checks. Following this training this officer conducted record checks directly rather than relying on other individuals for information. Legal record checks via a wireless network were also available for use at the time of interviews of potential participants. Through these procedures, many of the referral errors based on legal criteria were avoided. Delays in Court Proceedings. A frequent early problem involved court continuances of City and State defendants who had been screened as appropriate but had not yet appeared before a judge for approval of diversion. Hearings were not conducted and cases were delayed for at least a week because certain attorneys were assigned who were not familiar with their case or the Jail Diversion program, had had insufficient time to talk with the client, or could not locate the case file. Another problem involved transmission of documents to the Circuit Attorney for approval to drop or delay current charges. This was an essential step in the diversion process and unsigned documents slowed the entry process by as much as four weeks during which some potential participants were lost. Solution. The problem of continuances and court files was 6

12 corrected by having all potential St. Louis Jail Diversion Project participants files placed in redcolored folders and having one attorney assigned responsibility for locating files and for communicating information to the particular attorneys assigned to represent defendants. In addition, responsibility for assigning case files was given to one individual. Also, attorneys representing clients were briefed on the nature of Jail Diversion. Several attended monthly Jail Diversion meetings to improve their understanding. Evening and Weekend Hours. During this early period, the probation and parole officer responsible for SLJDP was available nine to five during weekdays only. Potential participants were often arrested at night and on weekends. There was insufficient time in the morning (starting at 8:00 a.m.) to interview and conduct record checks for such individuals before court at 10:00 a.m. Solution. Staff was added to permit expanded work hours. Outreach. Many eligible homeless persons cycled through the court system on a regular basis. Solution. Outreach to certain local shelters and organizations that served the homeless was instituted to find these potential clients before they were arrested. Interagency Communication. The St. Louis Jail Diversion Project experienced various breakdowns in communications among the cooperating agencies. Several of the organizations within the SLJDP coalition had staffing changes in late 2007, shortly after the project began accepting clients. Newly hired individuals needed time to learn planned project procedures within their own organizations and to become familiar with other participating organizations and the legal requirements of the program. This resulted in various delays in responding to inquiries, communicating SLJDP participant status and meeting evaluation timelines, including completing event and person tracking information and transmitting them in a timely fashion to the evaluator, referral of clients to service providers and ensuring that they arrived at appointments. Delays also resulted in problems of data collection and entry for project evaluators. Solution. Monthly Jail Diversion Program meetings were initiated to discuss ongoing problems. At monthly meetings, problems are discussed among all agency representatives. Weekly interagency staffing meetings were also scheduled where each participant, both new and existing, was discussed. Meetings and staffing made it possible to inform everyone of the identity of new participants, to provide evaluators with information on individuals screened out of the project, to provide feedback to court representatives about service plans, service contacts and participation in active cases, and other associated issues. These are some of the startup problems that the St. Louis Jail Diversion Project experienced during it early months that were discovered through the process evaluation and were addressed by the participating agencies. 7

13 3. Study Design and Data Collection The study design consisted of a process and an outcome evaluation. The process study considered problems and successes in implementing St. Louis Jail Diversion Project. The focus included progress in referring clients to the program, interagency communication, and many other issues. Select findings of two process evaluation reports in 2007 and 2008 are summarized in the previous section. Regarding outcomes, the evaluation was primarily designed to collect information on clients as they entered and progressed through the program. The data collection for the outcome evaluation was the responsibility of the Institute of Applied Research personnel and occurred between August 2007 to May The data was gathered from several sources and included information on: basic offender demographics, criminal history, mental health function, drug and alcohol use, treatment services, and discharge status of jail diversion participants. Information was collected through interviews and from various administrative databases. Screening. A screening instrument was utilized by intake personnel to make an initial determination of the appropriateness of potential clients for jail diversion and to indicate the reasons why individuals were ultimately screened in or out or declined to participate in the program. Potential clients that were determined to be appropriate on mental health and criminal justice grounds and who indicated a willingness to participate were provided with an intensive mental health assessment before being enrolled in the program. Evaluation Data Collection Procedures. Clients were scheduled to be interviewed at three points during their participation in the program: at program entry (baseline interview), six months after program entry, and twelve months after program entry. During each of these interviews a battery of data collection instruments was utilized. These are described more fully in Appendix B but included: 1) the Government Performance and Results Act (GPRA) instrument, 2) the D.C. Trauma Collaboration Study Violence and Trauma Screening tool, 3) the Posttraumatic Stress Disorder Checklist (PCL-C), 4) the Colorado Symptom Index 1991 (CSI), 5) a checklist of mental health and substance abuse services utilized, and 6) the CMHS-National Outcome Measures (NOMS). The evaluators also added 7) a series of supplemental questions to interviews that provided information in several areas not covered completely by the standardized data collection tools. Instruments 2 through 5 were required as part of the national cross-site evaluation conducted by the TAPA Center, and are referred to below as the TAPA sources. Instrument 7 is referred to as IAR in the list below. In addition, 8) record reviews were conducted of mental health and substance abuse service information for participants that continued participation in the program through the first six months (also referred to as IAR below). This included records of a variety of crisis services and ongoing services (see Appendix B for a complete listing). Finally, 9) the history of arrests were collected from official sources for the twelve-month periods before and after program entry. The sources and methods are described in Appendix B. 8

14 The following table shows the list of information collected from various data sources (see above for explanations of the source abbreviations). Demographics Type of Data Source Comment Mental Health, Substance Abuse, Well-Being & Needs Mental Health Diagnosis Mental health history of parents Trauma Screening of all JDP clients NOMS/TAPA IAR IAR TAPA Provided in collaboration with treatment provider Trauma Treatment services TAPA Provided in collaboration with UMSL-CTR Substance Use Previous 30 days Previous 6 months Use at enrollment, frequency of use Parental History of Substance Use Treatment Services Provided Service Modality Inpatient, Outpatient, and ER Treatment Drug Treatment Services Psychiatric Medication Case management Outcome Perception of Care Trauma Treatment Overall Health rating in past 30 days MH improvement/functioning scale Colorado symptom index Social Connectedness Scale Criminal Arrest and Jail Graduation/Termination Criminal Justice History Jail Days Served Outcome/completion/discharge Treatment Data TAPA IAR IAR IAR IAR TAPA IAR TAPA TAPA NOMS/IAR UMSL-CTR TAPA TAPA TAPA NOMS IAR IAR TAPA TAPA TAPA Obtained in coordination with City Probation Department Clients were individually interviewed by the evaluators and were provided with stipend payments for their participation. Data were entered by evaluators in appropriate national and cross-site databases. In addition, IAR maintained its own comprehensive database of all the information from various data sources. 4. The Evaluation Sample Enrollment under the SAMHSA grant began in August 2007 and extended through October During this period, 477 defendants were screened for the St. Louis Jail Diversion Project. Of these, 61.2 percent (292 individuals) were adjudicated in the St. Louis City municipal court system, 25.2 percent (120 individuals) were Missouri state court defendants, 11.5 percent (55 individuals) were referred from Federal Pretrial, and 2.1 percent (10 individuals) were referred from US Probation. 9

15 Of those screened, 169 (35.4 percent) were determined eligible, that is approximately, one in every three screened applicants. Of the 169 eligible individuals 164 agreed to the evaluation. 2 This eligibility rate was lower than generally expected during the planning phase when most in planning group assumed that the majority of individuals who met the criteria for type of offense and criminal history could be screened into the diversion program. Some of the barriers that resulted in this eligibility rate were discussed earlier in the summary of process evaluation report. Of the 164 SLJDP participants who agreed to the evaluation, all were interviewed at baseline, 130 (79.3 percent) were located at six-month follow-up, and 103 (62.8 percent) were found at the 12-month follow-up. As of April 2010, only 132 of the 164 participants had reached their 12-month reassessment date, and on this basis, 78.0 percent received a 12-month follow-up interview. Of the original 164 participants, 23 were active in jail diversion as of April 2010, 95 successfully completed the program, 41 were terminated or did not graduate, 3 were deceased, and 2 had received an administrative discharge. 5. Client Demographics Table 1 summarizes information on the race, gender, age, education, employment and housing status of all St. Louis Jail Diversion Project individuals who participated in the evaluation at baseline. Jail diversion participants were almost equally male and female. The majority (65.2 percent) of participants were between the ages of 35 and 54 with an average age of 41.9 years. Moreover, the large majority of the clients were black (68.9 percent), unemployed (82.9 percent), and not enrolled in school (98.8 percent); 45.1 percent of participants had less than 12 years of formal education, 32.9 percent graduated high school, 18.3 percent had some college, and 3.7 percent graduated from college. Regarding housing, 25.6 percent of participants were homeless at the time they were enrolled, 8.0 percent of participants were in jail for most of the previous 30 days, 22.6 percent had their own home and 38.4 percent were living with someone else at the time of enrollment. 2 One individual refused to participate in the evaluation; another was not located inside the required 7-day window; and three entered the program after the October 2009 cutoff date 10

16 Gender Table 1. Characteristics of SLJDP Participants at Intake Percent Male 49.4 Female 50.6 Race Percent Black 68.9 White 26.2 Multiracial 3.1 American Indian 1.8 Hispanic 1.8 Age Currently Employed Percent Yes, full-time 7.3 Yes, part-time 9.8 No 82.9 Education Less than 12 th grade 45.1 H.S. diploma/ged 32.9 Some college 18.3 Graduated college 3.7 Enrolled in School Yes 1.2 No 98.8 Marital Status Married 6.7 Single or widow 58.6 Divorced or separated 20.7 Living with significant other 14.0 Housing in past 30 days Institution 7.9 Own house/home 22.6 Someone else s home 38.4 Homeless 25.6 Other (residential, group, nursing, transitional) 5.5 Mean incomes reported in the baseline interview from various sources for 159 of the 164 participants who participated in the evaluation are shown in Table 2. The means were calculated only for the individuals actually reporting each type of income as shown. Mean total income was calculated from all 159 respondents. 11

17 Table 2. Income from Various Sources during the Previous 30 Days of SLJDP Participants at Intake Number Percent Mean Wages or money from paid employment $1,050 SSI,SSDI or disability $586 Social Security Income (SSA) $505 Food Stamps $160 Public assistance $219 Veteran's benefits $306 Unemployment or worker's compensation $725 Child support or alimony $75 Income from a spouse or partner's wages or other money $488 Retirement $1,200 Income from any illegal sources $1,216 Money from family members or friends $142 Income from other sources $765 Total Income of Respondents 159 $806 Mental Health Screening and Assessment Participants were classified into diagnostic categories based assessments of clinical staff. A majority (56.7 percent) of participants had severe and persistent mental illness. The primary diagnoses were Bipolar Disorder (26.2 percent) and Schizophrenia (30.5 percent). Additionally, 9.8 percent and 28.7 percent had a primary diagnosis of Post Traumatic Stress Disorder (PTSD) and Major Depression Disorder respectively. Figure 1 shows the primary diagnosis at time of diversion. Two individuals had a dual diagnosis of PTSD and Schizophrenia and were included under the Schizophrenia category. Three individuals had a dual diagnosis of PTSD and depression and were included under PTSD. Schizophrenia 30% PTSD 10% Other Axis II 2% Anxiety 3% Bipolar 26% Anorexia 1% Depression 29% Figure 1. Primary Diagnosis 12

18 Family History of Mental Illness and Substance Use Clients were also asked to report on substance use and mental illness in their family of origin. The majority (90.9 percent) of participants answered these questions, which were asked at intake and at six months. 3 Table 3 shows responses of participants. Only responses in which the participant specifically stated a mental illness or substance were counted as valid. If participants referred to their parent as crazy or has dementia or psychotic these were not included as a valid mental health response. More than half (53 percent) of respondents identified at least one family member with a drug or mental health problem. Table 3. Family Mental Health and Substance Abuse History Percent None 47.0 Mental Health 18.8 Drug or Alcohol Abuse 18.8 Both Mental illness & Substance Abuse 15.4 Substance Abuse History In the St. Louis Jail Diversion Project, 78 percent of individuals were identified as having an alcohol or drug abuse issue during the 12 months prior to enrollment. These individuals were also designated by the service provider to receive integrated treatment for a co-occurring disorder. Nearly a third (32.3 percent) had primarily drugs issues, 14.0 percent had mainly alcohol issues, and 31.7 percent had both alcohol and drug issues at enrollment. At intake, participants were asked several questions regarding their substance use during the 30 days before enrollment. As indicated in Table 4, 42.7% of the 164 individuals interviewed at baseline reported illegal drug use in the previous 30 days. With regard to drug choice, cocaine/crack and marijuana were the most commonly cited illegal drugs at 36.8%, and 29.4% of the study participants, respectively. One-half (50.0 percent) of participants using illegal drugs at baseline reported using on a daily basis. Likewise, more than one-third (35.0 percent) of alcohol users were using on a daily basis. Table 4. Top Six Drugs that Clients Reported Using at Time of Enrollment* 3 The questions were asked twice as a consistency check. In eight instances there was a discrepancy between the intake and six-month response usually related to alcohol use of parents. 13

19 Rank Percent 1 Any alcohol Any drug Cocaine/crack Marijuana Heroin Hallucinogens 3.7 * Individuals duplicated in categories Spirituality Clients were also asked questions about their spiritual practices. Although not pursued beyond asking clients about their attitudes and practices, this is considered by many to be an important dimension of healing and change, particularly for individuals with drug and alcohol addictions. Religious communities may also be a source of moral and physical support for their individual members. In general about eight of every ten clients indicated that either they attended church or that they considered spirituality important (baseline: 81.1 percent; six months: 86.2 percent; twelve months: 78.8 percent). 6. Criminal History and Screening Criminal history data were collected from official sources (Regional Justice Information Services Inquiry and Missouri Uniform Law Enforcement System) and included the index (target) offenses and all arrests that occurred 12 months prior to and 12 months following enrollment into the jail diversion program Jurisdiction of Charge. Among the 164 jail diversion participants included in the evaluation, 37 (22.6 percent) were Federal referrals with non-violent felony offenses, 22 (13.4 percent) were State referrals with misdemeanor charges and 105 (64.0 percent) were City offenders with city ordinance violations. Of the 37 federal referrals that were eligible and participated in Diversion, 29 (78.4%) originated from the U.S. Federal Pretrial office and 8 (21.6%) came from U.S. Probation. Types of Charges. The primary offenses of eligible and ineligible applicants are shown in Table 5. The categories reflect the checklist available to screeners. Both groups had similar types and distributions of charges with the exception that diverted participants had fewer potentially violent offenses. Typical minor charges of JDP clients include disorderly conduct, public intoxication, public urination, prostitution, traffic infraction, indecent exposure, and loitering. Typical property offenses included trespassing, fraud, insufficient funds check writing, shoplifting, and petty larceny. 14

20 Table 5. Major Charge of Eligible and Ineligible SLJDP Applicants Charge % Eligible % Ineligible Minor Offense Property Offense Drug Offense Potentially Violent Offense Unspecified Other Crime Reasons for Ineligibility. Reasons that 308 individuals were found ineligible are shown in Table 6. The large majority of cases, more than two-thirds, were screened out for legal reasons or individuals dropped out before enrolling in the program. Legal reasons primarily included charges for violent offenses and outstanding warrants or holds in other jurisdictions. Individuals who dropped out most often did so because they failed to appear in court, failed to follow-up with scheduled mental health assessments or failed to meet with their probation officer within 90 days from initial screening date. Less than a dozen ineligibles were later enrolled and eligible for a baseline interview. Table 6. Reasons for Ineligibility of Potential Participants Percent Dropped out during screening 41.9 Legal criteria 28.9 Psychological criteria 13.8 Duplication of services 9.1 Released from jail 5.0 Other Reason 1.3 Total The remaining third were spread across several criteria. Psychological criteria refers to individuals who were not considered appropriate for mental health services (no mental illness) after psychological screening or assessment. Duplication of services indicates that individuals were already receiving mental health services through another program. A few individuals were released from jail and four were under the minimum enrollment age of Treatment Services The primary service providers for jail diversion participants were Community Alternatives Inc. (80.5 percent) and BJC Behavioral Health (14.6 percent). A small number of individuals (4.9 percent) received services from both providers for a significant period of time prior to having a final assignment. In addition, the Center for Trauma Recovery (CTR) of 15

21 University of Missouri-St. Louis (UMSL) served 12.8 percent of the St. Louis Jail Diversion Project population. Intensive case management services included: 1) development of a comprehensive plan for treatment services; 2) appointment for psychiatric services and medication management; 3) assistance with other needs, such as shelter, employment, transportation, life skills, benefits information, etc.; 4) assistance in acquiring documents such as birth certificate and social security cards; 5) contact with case manager 3-5 times per week for approximately 90 days.; 6) group therapy; and 7) upon stabilization, transfer to other ongoing support services in the community. Treatment Modalities. Assertive Community Treatment (ACT) services were received by 20.1 percent of participants while 14.6 percent received Intensive Case Management and 60.0 percent received brief case management. In Table 7 the top ten services that treatment providers reported providing to clients are shown. Table 8 ranks the general categories of services that clients reported receiving after six-months in the program. Table 7. Top Ten Services Provided Rank Percent 1 Mental Health Screening & Assessment Mental Health Services Case Management Transportation Psychiatric services and medication management Substance Abuse treatment/counseling Co-Occurring Disorder Services Housing Support Employment Services Trauma Specific 16.9 Table 8. Top 6 Self-Reported Service Use in 6 months following JDP Enrollment Rank Service Received Percent 1 Case Management Saw doctor/nurse about psychiatric medications Outpatient Treatment (Individual/group therapy, day or other treatment_ Vocational/rehabilitation Services (supported employment, psychosocial rehabilitation, vocational counseling, etc) Community Support Services (outreach while homeless, legal or consumer advocacy, payee services, etc) Received Detoxification services for an alcohol or drug problem 20.0 Inpatient, Outpatient and Emergency Room Treatment Table 9 presents the source and location of services provided to participants at the beginning of participation and at six and twelve months. Outpatient treatment for drug and alcohol abuse approximately doubled after six months but by the twelfth month declined to 16

22 levels seen at intake. Mental health outpatient treatment at six months was more than triple levels at intake and remained near that level after twelve months. On the other hand, mental health inpatient and emergency room treatment generally declined from levels at intake. The latter shows that expensive inpatient psychiatric hospitalization and trips to emergency room can be reduced by enrolling clients in jail diversion and establishing routine mental health and substance abuse treatment. Table 9. Types of Treatment Provided during the Previous 30 Days at Intake to the Program and at Six Months and Twelve Months in the Program Intake Six months Twelve months Drug & Alcohol Abuse Inpatient 3.7% 2.3% 1.9% Outpatient 9.1% 17.7% 9.7% Treatment for Mental & Emotional Difficulties Inpatient 12.4% 1.5% 6.8% Outpatient 20.7% 65.4% 56.3% Emergency Room Treatment Mental/emotional difficulties 11.2% 2.3% 7.8% Alcohol or Drug abuse 5.6% 1.5% 0% Referral of Clients to UMSL-Center for Trauma Recovery The PTSD Checklist-Civilians Version (PCL-C 4, 5 ), a 17-item self-report measure, was used to assess participants for Post Traumatic Stress Disorder (PTSD). The PCL is one of only three well-established self-report instruments to correspond closely with each of the 17 DSM defined PTSD symptoms (Ruggiero, Rheingold, Resnick, & Kilpatrick, 2006). Based on a traditional and recommended cutoff score of 50, the observed PTSD prevalence rate of all Jail Diversion participants was 60.1 percent at the time of enrollment. Three participants refused to answer questions related to past trauma. The referral of jail diversion clients to the UMSL-CTR proceeded slowly and various problems were identified during the first (service) year of the project. These included difficulty agreeing which jail diversion clients were appropriate for PTSD treatment, whether clients should be given group or individual therapy, and whether a formal diagnosis was necessary before acceptance by the service provider. Other difficulties identified were assisting participants in making appointments, integrating treatment for substance use and PTSD, and finding where services were located. As a result, services were sometimes delayed. These problems were resolved during the second service year. The CTR agreed to provide treatment to all clients referred (within the client number limits set for the CTR), to provide services at Community Alternatives, and to schedule seven clinical hours per week for individual PTSD therapy by an CTR therapist. A formal referral process was established with a treatment plan and follow-up for 4 Weathers FW, Litz BT, Herman DS, Huska JA, Keane TM. The PTSD checklist: reliability, validity, and diagnostic utility. Presented at the Annual Meeting of the International Society for Traumatic Stress Studies. San Antonio, TX; October Blanchard EB, Jones-Alexander J, Buckley TC, Forneris CA. Psychometric properties of the PTSD Checklist (PCL). Behav Res Ther 1996; 34:

23 all clients referred for PTSD treatment. PSTD Treatment at the CTR involves 12 sessions, not including an initial intake session and a follow-up session. The UMSL-CTR provided services appropriate to a primary diagnosis of PTSD to 12.8 percent of clients. These referrals were based on a short list of questions used by initial mental health screeners and not on the PCL-C utilized by evaluators. As noted above, PCL-C screening indicated that 60.1 percent of all study participants met criteria for active PTSD symptomatology at intake. This considerable difference might be resolved by having CTR staff evaluate all SLJDP clients accepted for services, since CTR staff also utilize more comprehensive measures of PTSD. Another option would be for mental health staff to include the PCL-C as part of their initial mental health assessment. Overall, qualitative feedback from those clients who did receive services through UMSL-CTR was very positive and drop-out rates were low. Client s Perception of Problem At the time of enrollment, participants were asked the following question: If the diversion program could help you in one area in you life, what would that problem area be? Participants were encouraged to identify more than one area. Figure 2 shows the responses for participants who indicated a problem area. Evaluators began asking participants this question at enrollment near the end of the first grant year. Therefore, the question was answered by 98 participants (60% of total enrolled JDP population). The largest category concerned stable housing. This reflects the situation of many of the city and state defendants that were referred to jail diversion, who were homeless or on the verge of homelessness. The next largest category (mental stability/coping with daily life) might be expected for individuals diagnosed with psychiatric conditions of the types shown in Figure 1. In general, the responses show a positive level of self-awareness and awareness of needs. Medication management Substance Abuse Recovery Employment Assistance Financial Assistance Mental stability/coping with Daily Life 42.8 Stable Housing 47.9 Percent reporting Figure 2. Client Identified Needs at Time of Enrollment (n=98) 18